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Ann Epidemiol. 2012 June ; 22(6): 446455. doi:10.1016/j.annepidem.2012.04.018.
Epidemiology, Policy, and Racial/Ethnic Minority Health

Disparities
Olivia Carter-Pokras, Ph.D.1, Tabatha Offutt-Powell, DrPH, MPH2, Jay S. Kaufman, Ph.D.3,
Wayne Giles, MD, MPH4, and Vickie Mays, Ph.D., MSPH5
1Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland
College Park
2Department
of Epidemiology, School of Public Health, University of North Texas Health Science
Center
3Department
of Epidemiology, Biostatistics, and Occupational Health, McGill University
4Division
of Adult and Community Health, National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and Prevention
5Department
of Health Services, School of Public Health, and Department of Psychology

University of California-Los Angeles
Abstract
PurposeEpidemiologists have long contributed to policy efforts to address health disparities.
Three examples illustrate how epidemiologists have addressed health disparities in the U.S. and
abroad through a social determinants of health lens.
MethodsTo identify examples of how epidemiologic research has been applied to reduce
health disparities, we queried epidemiologists engaged in disparities research in the U.S., Canada,
and New Zealand, and drew upon the scientific literature.
ResultsResulting examples covered a wide range of topic areas. Three areas selected for their
contributions to policy were: 1) epidemiology's role in definition and measurement, 2) the study of
housing and asthma, and 3) the study of food policy strategies to reduce health disparities. While
epidemiologic research has done much to define and quantify health inequalities, it has generally
been less successful at producing evidence that would identify targets for health equity
intervention. Epidemiologists have a role to play in measurement and basic surveillance, etiologic
research, intervention research, and evaluation research. However, our training and funding
sources generally place greatest emphasis on surveillance and etiologic research. Conclusions: The
complexity of health disparities requires better training for epidemiologists to effectively work in
multidisciplinary teams. Together we can evaluate contextual and multilevel contributions to
disease and study intervention programs in order to gain better insights into evidenced-based
health equity strategies.
2012 Elsevier Inc. All rights reserved.

Corresponding Author: Olivia Carter-Pokras, Ph.D., Associate Professor, Department of Epidemiology and Biostatistics, University of
Maryland College Park School of Public Health, 2234G SPH Bldg., College Park, MD 20742, Phone: 301-405-8037 (office),
301-257-6106 (cell), Fax: 301-314-9366, opokras@umd.edu.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
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Carter-Pokras et al.
Page 2
Keywords
Health Status Disparities; Healthcare Disparities; Minority Health; Epidemiology; Policy;

Socioeconomic Factors
If all epidemiologists stop short of helping to affect policy, then the voice of
science will be lost from making decisions that most affect the health of the
public. (1).
Introduction
Results of the 2010 U.S. Census suggest that as the growth of Black, Hispanic and Asian
ethnic groups continues to accelerate, there will be a minority majority as early as 2042,
when Hispanics (of any race) will comprise 24 percent of the population, Blacks 15 percent
and Asians 8 percent (2). This majority of racial/ethnic minorities will occur even earlier
(2023) among children and adolescents (2). Addressing their health needs, especially in the
face of growing evidence of continued and severe health disparities for many racial/ethnic
groups, is challenging for health care and public health.
Knowledge of the range and complexity of health disparities has evolved as a result of data
collection on race and ethnicity in epidemiologic surveillance and research (3). In addition,
epidemiologists have long been involved in policy efforts to address health disparities
beyond the conduct, analysis, interpretation and dissemination of health data. These efforts
have included preparation of governmental reports (4-6), managing policy offices (7),
identifying priorities for initiatives (8-10), and providing policy guidance (11).
There are many routes from epidemiologic activity to policy formation: surveillance raises
awareness of an issue, measurement research progressively refines exposures and outcomes,
etiologic research identifies causal relations in natural settings, intervention research pilots
potential actions, and evaluation research considers impacts of policies. The development
and implementation of policies, including laws, regulations, and judicial decrees, includes
advocacy in support of all these efforts. Albert Szent-Gyorgi described three faces of
science as: 1) a way of thinking about things (evidence, objectivity, and a cool head), 2)
the results and their applications, and 3) the scientist's moral code (12). The three faces are
interrelated: from science come results and these may be applied through attendant public
policies.
Epidemiologists wear all three of these faces, and have come to recognize not only the
importance of values in many aspects of professional practice, but also the need for ethical
guidance that regulates our public behavior. Representing the science of public health,
epidemiologists are naturally the most qualified to interpret the epidemiologic studies used
to set public health policy. As Weed has noted, the bioethical principle of beneficence
provides moral justification for advocacy (12).
Epidemiologic research to address health disparities has also evolved, through the four
phases of health disparities research (13). The first phase of health disparities research has
been the identification of the nature and extent of disparities (4). The second phase identified
underlying factors for racial, ethnic and socioeconomic disparities. The third phase, the
development and implementation of interventions (14), increasingly includes
transdisciplinary research, community engagement, and knowledge translation. The fourth
phase encompasses a mixed methods approach to evaluation of comprehensive, multilevel
interventions. Classical epidemiologic approaches and training provide a good basis for
contributions to the first two phases, however, this review highlights a need to expand
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training for epidemiologists to encompass the complexity of health disparities and address
contextual social determinants that contribute to disease, and the foundation of successful
health equity strategies that can reduce and/or eliminate health disparities.
All health behaviors, policies and interventions can impact on disparities. For this reason,
we focus our attention on social determinants of health: policies and interventions that are
targeted at social conditions, rather than medical care or individual behavior change. There
is a long history of interventions on social conditions intended to reduce disparities. For
example, Sara Josephine Baker (18731945) implemented public health interventions
among the poor in New York City, including licensing midwives, encouraging
breastfeeding, providing safe pasteurized milk and school lunches, school-based screening
and maternal education initiatives (15). Likewise, Joseph Goldberger (18741929) was an
advocate for scientific and social recognition of the links between poverty and disease. He
noted that alleviation of poverty improved nutrition, which reduced pellagra in the rural poor
(16).
Social context interventions tend to be non-specific in their impacts, but are often promoted
on the basis of multiple motivations. Because they are upstream they generally have
diverse consequences (intended and unintended). Social context interventions are also
necessarily contextual, and observed effects in one setting often don't generalize well to
others. Finally, social conditions are frequently associated with health outcomes in
observational data, making both causal inference and anticipation of the effects of policy
modifications inherently difficult.
In this review, we provide three examples of how epidemiologists have addressed health
disparities through a social determinants of health lens. To identify examples of how
epidemiology approaches health disparities, we broadly queried epidemiologists engaged in
health disparities research in the US, Canada and New Zealand through listservs, LinkedIn,
and personal communication. Potential cases offered covered a wide range of topics areas,
including asthma, cancer screening and management, cardiovascular disease, data
development, nutrition, food pricing, sexually transmitted infections, HIV/AIDS, child and
adult immunizations, health services, and other topics. We were interested in highlighting
examples that had a social determinants of health focus, had not already been discussed in
the American College of Epidemiology's epidemiology and policy series, and had multiple
applications, either in the U.S. or abroad.
Theoretical Framework for Causal Effects of Policies

Health policy interventions are enacted among populations to influence outcomes through
various mechanisms. The impacts of population-level policies lead to individual-level
effects measured at the aggregate level (17). Consider the example of a policy designed to
increase physical activity among children attending school-based physical education classes
(18, 19). At the individual level, children may respond to the program by increasing their
physical activity while attending classes. Suppose that each targeted school later reports that
the overall prevalence of childhood obesity has decreased among children attending the
school. It therefore appears that the physical activity policy has influenced childhood obesity
rates. But is the observed change in obesity equal to the causal effect of the intervention?
Could the measured effect be confounded by social or behavioral factors that affect obesity
in the students at some of the schools?
If such factors were to exist, then it would be necessary to adjust for these confounding
variables in a statistical model. Epidemiologists often use a causal diagram to illustrate
relations among factors relevant to an exposure-outcome association, to facilitate
identification of a sufficient set of adjustments to reduce confounding, and to illustrate
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inappropriate adjustment for variables that are not confounders of the exposure effect of
interest. A key criterion that epidemiologists should consider is whether adjusted factors are
affected by the policy as opposed to determinants of policy implementation.
The following example provides an illustration of a graphical model to conceptualize the
influence of a policy intervention on poor living conditions and its subsequent effect on
childhood asthma exacerbations. Because causal diagrams require qualitative determinations
of which factors to include, a critical review of existing evidence is required. Furthermore,
causal diagrams present structural relations using available evidence at a given snapshot in
time. Fortunately, these diagrams can be modified as new evidence becomes available. We
encourage epidemiologists to develop and share their proposed graphical models with other
researchers to promote transparency and to aid in the progressive accumulation of
knowledge. Connecting the graphical model with the statistical modeling approach can
promote a greater understanding of the analytic assumptions, and this can be helpful to the
evaluation process needed to translate scientific findings into policy innovations (20).
Recent research suggests that poor living conditions (e.g., indoor allergens, environmental
tobacco smoke, etc.) exacerbate asthma in children (21). Policies have been enacted to
remediate these environmental factors from households (22). We are interested in
quantifying the magnitude of the effect of the policy intervention on childhood asthma
exacerbations. We recognize that the social environment and its effects on individual and
population health occur at multiple levels and involve dynamic social interactions (23);
therefore we use a simplified graphical model as a tool to illustrate some conditional
dependencies among the interrelated variables in our small universe of measured factors that
influence the outcome (24, 25).
Figure 1 is a graphical representation of the relations among some of the factors that
influence childhood asthma exacerbations. This graph depicts one of many plausible
mechanisms for the sequencing and inter-relations between the policy, the outcome and
some important covariates. This illustrates the dependencies among the many levels in the
data and provides transparency regarding assumptions so that they can be discussed and
critiqued. These factors can be described as social (e.g., socioeconomic status),
environmental (e.g., outdoor air pollution), and genetic variations, and can be defined
concurrently at the individual and population levels. For example, outdoor air pollution
occurs at a population level affecting individual level exposures to pollutants that can lead to
asthma exacerbations (26). Circulating respiratory infections in the community, which occur
throughout the year, increase the occurrence of asthmatic exacerbations in individual
children infected with rhinoviruses, influenza, or other respiratory viruses (27).
To estimate the causal effect on childhood asthma exacerbations of a potential policy of

intervening on poor housing conditions, it is necessary to identify a sufficient set of
covariates for which to adjust in an analytic model. Based on our assumptions, no
adjustment is indicated because the policy is exogenous (i.e., there are no arrows leading
into the policy node (25)). Adjustment for other variables, such as socioeconomic status
(SES), which is not a cause of the policy intervention, would therefore result in a biased
estimate of the total effect of the policy. While the policy is unconfounded in this network of
factors, another exposure of potential interest may be. For example, we may be interested in
determining whether installation of allergen reducing air filters in homes (as a
subcomponent of a multi-faceted, in-home tailored intervention (28)) reduces childhood
asthma compared to children living in homes without air filters (29). In this exposureoutcome relation, a sufficient set of covariates to adjust may include social factors such as
SES. In more realistically elaborate graphs, it will often be the case that no set of observed
variables would be sufficient for complete confounding control (30).
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The Role of Epidemiology in Definition and Measurement

A primary goal of epidemiologic research is to provide an evidentiary basis for informed

policy decisions, and this is no less true for policies that impact health through broad social
determinants such as food, housing, schooling and employment. These upstream factors
are all subject to important policy decisions on a routine basis, from tax and subsidy policies
to targeted interventions, and clearly have the potential to affect health disparities positively
or negatively. While health disparities are not the only consideration in setting such policies,
they are an important one that can impact both cost-benefit calculations as well as the
perceived social desirability of one policy over another in terms of overall equity, justice and
social desirability.
Epidemiologic study of social determinants in relation to health disparities entails many

significant challenges. The subject matter relevant to these exposures and the policies that
regulate their distributions is often outside of typical training in epidemiology. Much of the
available funding is tied to specific disease categories, but social determinants often have
broad impacts across many diseases. Causal inference is difficult because the exposures are
usually far from exogenous, leading many scientists to seek out natural experiments or other
sources of random variation with which to make stronger conclusions (31). Finally,
generalizability is often questionable because the exposures are experienced within social
contexts that differ greatly across societies or race, gender, and class subgroups within
societies.
Much descriptive epidemiology regarding health disparities is published each year. This
work is constantly evolving and being refined by attention to novel axes of disparity (e.g.,
sexual orientation, wealth, and place) and by increasingly diverse methods of defining
composite outcomes, such as disability adjusted life-years (DALYs), quality adjusted lifeyears (QALYs) and other composite measures (32). The definition of health disparity (and
related terms such as inequality and inequity) has itself endured continual epidemiologic
critique on conceptual grounds. Increasingly an emerging literature has challenged routine
approaches of simple health comparisons across divergent social groups (33-37).
One major role for epidemiology on health disparities policy is through definition,
classification and measurement, fundamental issues that are necessary for all evidencedbased decisions, and for which epidemiology has a long standing tradition of methodologic
development. This work includes exposure assessment, outcome classification, and analysis
of measurement error. On the exposure side, there have been dramatic developments in
recent decades in the assessment of social determinants of health, in both conceptual and
operational terms. Epidemiologists have been at the forefront in public health of refining
conceptually valid and practically implementable measures of constructs such as racism,
segregation, inequality, educational attainment and various forms of wealth and poverty in
health studies (23). Likewise, on the outcomes side, assessment of disparities has evolved to
encompass a wide variety of measures, each with unique advantages with respect to absolute
or relative comparisons and the scaling of the dimension over which the outcomes are
contrasted (38,39). These developments are crucial because the use of different exposure
and outcome measures can generate dramatically different understandings of the
relationships (40). Moreover, common descriptive techniques, such as routine
standardization, can have artifactual influences on the disparity patterns that could sway
policy-makers into an inaccurate perception of changes over time (41). One example that
continues to motivate further work in the area of standardization is the collection of data on
race and ethnicity. Current efforts are underway by HHS as directed by the Affordable Care
Act to improve the monitoring of inequities not only by race but also by ethnicity, primary
language, sex, and disability status. (42-45).
Page 6
A concrete example in which the development of exposure indices has influenced policy for
reduction of disparities is the advent of neighborhood quality indices, which summarize a
wide variety of social indicators. For example, the Connecticut Association of Directors of
Health's Health Equity Index assesses numerous domains including economic security,
educational resources, transportation, civic involvement, housing quality, and environmental
quality (46). It is used in policy evaluations to assess community change in relation to
various interventions and policies.
Another example of neighborhood quality indices comes from New Zealand's Social
Reports (Te Prongo Oranga Tangata), which are used by government agencies to monitor
social progress in health disparities (47). These reports have now gained a level of
prominence in central and local government as a tool for surveillance within that country. In
qualitative assessments of the value of this tool for policy makers, senior health officials
from the Ministry of Health asserted that the institution of routine assessment and reporting,
and the availability of content from these reports have assisted in both raising awareness and
stimulating action to address the social determinants of health and improve health equity,
both within and outside the health sector. Amongst civil society actors, too, these reports
have gained currency with health advocacy agencies, health service providers, indigenous
organizations, academic audiences and the media.
The Example of Housing and Asthma

Housing interventions to reduce asthma exacerbations among racial and ethnic minorities
and the poor such as those conducted in Seattle-King County, Washington; Chicago,
Illinois; and New Zealand are another example of a social contextual intervention to reduce
health disparities. Asthma disproportionately affects minority and disadvantaged children,
including residents of federally assisted housing (48-50). Racial and ethnic minority and
low-income children are more likely to live in substandard housing with greater exposure to
allergens and higher asthma sensitization rates due to crowding, pest infestations, poor
ventilation, deteriorated carpeting, excessive moisture and dampness, poor ventilation, and
structural deficits (51).
Since environmental conditions in the home can exacerbate asthma symptoms, housing
interventions have included home assessment for asthma triggers (e.g., environmental
tobacco smoke, dust mites, outdoor air pollution, cockroach allergen, pets, mold, wood
smoke), provision of products and services to reduce exposure to asthma triggers (e.g.,
mattress cases, chemical methods to reduce dust mites), and asthma education on
identification of asthma triggers and how to reduce exposure. Home-based multi-trigger,
multi-component interventions with an environmental focus are recommended by the Task
Force on Community Preventive Services for children and adolescents, but, not for adults
due to insufficient evidence (52).
Several of the housing intervention programs have clear ties to community needs
assessments. For example, Seattle's King County Department of Public Health conducts a
health survey every three years and analyzes data by region and health planning area.
Stemming from disparities identified in this survey, the Healthy Homes Project aimed to
reduce exposure to indoor asthma triggers among low-income urban children with asthma
(53-55). This project has been translated by Sinai Health Systems in Chicago (56), and
included home visits by community health workers (57, 58).
The eight phases of the Sinai Model for Reducing Health Disparities and Improving Health
included: a community survey (2002-2003), analysis and comparison of results with national
and state data to locate community-level differences, wide dissemination of findings
(2004-2007), partnership with community organizations to prioritize health concerns,
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location/development of potentially effective interventions, work with community based

organizations (CBOs) to locate funding for interventions, implementation of interventions
(e.g., The Westside Children's Asthma Partnership), and evaluation of interventions (59).
Many challenges have been identified. For example, some medical center projects have been
criticized, leading to shifts in the handling of factors such as community interaction and
indirect costs. Some communities have not mounted interventions related to survey findings.
In some cases budget crises and loss of funding have affected sustainability. In all cases,
broad generalizability remains a concern. Oftentimes, limited funding for evaluation and
dissemination has hindered the ability to assess program impact on participants and the
larger community. Indeed, many housing intervention studies fail to examine the
effectiveness of interventions over time (60, 61). Few housing interventions have moved
from efficacy to effectiveness studies.
Multilevel interventions pose challenges for evaluation, making it hard to tease out the
impact of specific components. As an example, community partners of Seattle-King
County's Healthy Homes Project argued against having a usual care comparison group and
therefore both intervention arms incorporated multiple components. Their low-intensity
comparison group received a combination of home assessment of triggers, home action
plans, limited education during the assessment visit and bedding encasements (62).
Evidence is lacking or mixed for key components of multilevel housing interventions in

addressing asthma. Trials of chemical and/or physical methods to reduce dust mite exposure
to date have sometimes been of poor quality, as noted by a Cochrane review which found
that control measures to reduce exposure to dust mites or their products had no effect on
lung function, asthma symptoms or medication scores (63). Moderate-quality evidence
exists that repairing houses or remediation decreased asthma-related symptoms among
adults, and acute care visits among children (64). Published reviews indicate evidence to
support three of 11 interventions for asthma: multi-faceted, in-home, tailored asthma
interventions; integrated pest management (cockroach allergen reduction); and moisture
intrusion elimination (61, 65, 66). Recently, the Breathe Easy home project found that
children and adolescents with asthma who moved into an asthma-friendly home (moisturereduction features, enhanced ventilation systems, and materials that minimized dust and offgassing) experienced large decreases in asthma morbidity and trigger exposure (67).
For epidemiologists to more fully contribute to development and evaluation of interventions

such as these, education and training are needed that integrate contextual social and political
aspects of community involvement, process and outcome evaluation of community level
interventions, qualitative and mixed methods, and analytic techniques such as multilevel
modeling (68). Epidemiologists also need to be prepared to address generalizability and
sustainability concerns. Because of differences in populations, climate, predominant type of
housing, housing codes and policies (e.g., enforcement, new construction guidelines), and
exposure to other indoor and outdoor pollutants, modifications may be needed to match
interventions to individual community needs and context. Contextualizability may be a
better to concept to consider, since different places have different profiles. Detailed
information on the content of interventions and context, and the processes that led to the
interventions, are therefore needed to address generalizability concerns (60).
Food Policy Strategies to Reduce Health Disparities

Unequal distribution of healthy foods -- a significant factor in health disparities is an
example of a contextual issue identified through epidemiologic data. Policies that increase
access to healthy foods include healthy food financing initiatives or zoning ordinances to
support farmers markets and corner store initiatives; zoning and other city ordinances that
Page 8
decrease access to unhealthy foods (e.g., limit fast-food restaurants); and pricing strategies
that make healthy foods less expensive and unhealthy foods more expensive. For each of
these policies, evaluation is key to documentation of the baseline disparity, and ensuring that
short term and long term outcomes lead to a reduction in health disparities.
Over the last 10 years, a growing number of communities have implemented policies to
increase access to healthy foods with a particular focus on areas of food deserts and food
swamps. Promising polices include providing incentives that allow the installation of
refrigeration units for the sale of fresh fruits and vegetables in convenience or corner stores;
loans and zoning ordinances that promote large grocery stores, farmers markets and corner
stores particularly within food deserts or food swamps; decreasing access to unhealthy foods
through zoning ordinances such as those restricting fast food establishments; and
implementing price strategies that reduce the costs for health foods through consolidated
bids and Electronic Benefit Transfer (EBT)/Supplemental Nutrition Assistance Program
(SNAP), (69, 70).
A number of communities, such as Louisville, Seattle and Philadelphia are working with
local store owners to convert their retail establishments for the sale of fresh fruits and
vegetables and healthy foods. In Charlotte, North Carolina, a farmers market was established
on the grounds of the county health department through a change in the zoning ordinance.
Between 2001 and 2005, the daily consumption of five or more fruits and vegetables among
African Americans in North Carolina increased from 23.1% to 25.3%, while overall statewide consumption of fruits and vegetable decreased from 21.7% to 17.5% (71). The
documented increase in fruits and vegetable consumption among African Americans in
North Carolina at a time when the general trend was in the opposite direction represents
important changes in health behavior, however, additional evaluation is needed to determine
the long term impact of these policies.
In addition to increasing access to healthy foods, another important strategy is decreasing

access to unhealthy food. As an initial step, the community of South Los Angeles (LA)
documented the paucity of large, regional and national chain supermarkets and
overabundance of small local markets and convenience stores in South LA when compared
with West LA (72). The community used this information to advocate for a two year
moratorium of new fast food restaurants opening in the community; the rationale being that
during this moratorium a plan would be developed and implemented to bring grocery stores
and more healthy eating options into South LA (70). During the moratorium, several small
stores started selling fruits and vegetables, the first farmers market in the region started
accepting Women, Infants and Children (WIC) checks, and new supermarkets moved into
South LA in 2010 (70, 73, 74). Subsequently the Los Angeles municipal code was amended
to limit new fast food establishments from opening within mile of an existing fast food
establishment (73). While the impact of this moratorium on the health of the community still
needs to be evaluated, West-Adam Baldwin Hills LA has passed a similar ordinance, and the
city of Detroit is considering a similar ordinance. Menu calorie labeling has previously been
suggested to have a bigger impact on overweight and obesity than banning new fast-food
establishments (75) given continued access to unhealthy foods at gas stations and
convenience stores. A recent analysis of 15 years of longitudinal data from the Coronary
Artery Risk Development in Young Adults (CARDIA) study found evidence that zoning
restrictions on fast food restaurants within three kilometers of low-income residents reduced
consumption of fast food, while better access to supermarkets did not improve people's diets
(76). The strongest factors in food choice were income and proximity to fast-food
restaurants.
Page 9
Pricing strategies include enhanced usability of the SNAP, WIC, and EBT at healthier food
vendors, working with grocers in placement and pricing of healthier foods, and consolidated
bid purchase by large organizations such as school districts, large worksites, and local
governments. Consolidated bids allow large purchasers to buy healthier foods at a reduced
price passing the savings onto the consumer. A number of communities are working to
enhance the use of SNAP/EBT cards at healthier vendors including farmers markets and
convenience stores. There are various models for this intervention, for example the policy in
which consumers who purchase $3 of fruits and vegetables receive two additional dollars in
bonus bucks for the purchase of additional fruits and vegetables. While such strategies
seem quite promising, their impact (particularly long term) in relation to health disparities
has not been fully evaluated. Despite the common perception that farmers markets are not
viable for low income populations due to their costs, little research has been conducted
comparing costs between supermarkets and farmers markets (77).
The implementation of food policies, particularly those that are jurisdiction-wide, should be
an effective strategy to reducing disparities in health. These policy approaches should align
with health equity since the entire population is covered by the intervention. Unfortunately,
a jurisdiction-wide approach could inadvertently exacerbate health disparities if differential
barriers exist in the adoption, implementation, and enforcement of the policy by the
community or a sub-population. For example, in 1988 the US Food and Drug
Administration required the fortification of enriched cereal grain products with folic acid
and manufacturers voluntarily added folate to many ready-to-eat cereals. This strategy was
extremely effective in increasing folate levels for women of childbearing age, greatly
reducing the rate of neural tube defects in the US (78). Unfortunately, because of differential
access to folate-rich foods, racial and ethnic disparities in folate remain (78, 79). Integrating
a health disparities assessment into policy planning and implementation can help to ensure
that the implementation of policies lessen, and not widen, health disparities. This includes
the development of milestones that are specifically aimed at advancing health equity,
targeting efforts to sub-populations experiencing greater burden, working with organizations
and in settings to reach underserved populations, and by addressing barriers to and potential
unintended consequences of policy strategies. While some policy approaches may seem
promising for addressing health inequities, they may be insufficient in practice without
strategic actions to alleviate barriers that sub-populations face in terms of the
implementation, enforcement, and sustainability as well as any unintended consequences of
the policy.
Conclusions
These three examples illustrate that epidemiologists working in the area of health disparities
are faced with a number of dilemmas. First, the complexity of the topic often demands
innovation in methodological and statistical approaches, including the collection or
identification of data not typically encountered in the academic formation of
epidemiologists. Qualitative data may often be necessary to help understand the culture and
context in which the disease or risk factor occurs in order to determine who and what to
include in surveillance activities. As an example, in the early history of the HIV/AIDS
epidemic it was thought that categories of people, rather than their behaviors, were the
sources of risk. In this way, gay men and Haitians were identified as targets of surveillance,
but only later were the risk behaviors described (e.g., men having sex with men, injection
drug use), as well as their social patterning. Nuanced approaches of interviewing and
studying cultural group norms and behaviors helped epidemiologists to eventually ask better
questions in order to determine and provide guidance on how to reduce risk of infection. It
was also in those qualitative approaches that quantitative questions were included in
Page 10
surveillance, leading to further insights about the socially patterned differences in HIV
incidence by race/ethnicity, gender and sexual orientation (37, 80).
Health disparities researchers face unique challenges in the translation of their findings into
policy, since interventions often involve changes outside the health care enterprise,
including redistribution of resources, affirmative action programs or opposition to actions
that foster social inequality. Epidemiologists, like other health professionals, have
traditionally avoided explicit connections between their scientific findings and social justice
motivations of that work (35, 37). This determination to engage in value free science and let
others determine how best to apply the findings of epidemiologic research to policy is a
long-standing value within the discipline, and the source of much tension in the application
of epidemiology to the study of disparities.
Spasoff (1999) suggested that policy development has five key steps and that epidemiologic
data are central as a guide in each of those steps (81). The first step is the assessment of
population health, in which the role of epidemiology is to define the population and to use
surveillance to identify trends and patterns and to assess risks and health needs. While the
field has demonstrated important contributions to this first step, it has done less to follow up
with the remaining steps which involve producing evidence for successful health equity
interventions. To some extent, this may result from a greater emphasis on individual level
risk factor identification versus evaluation of intervention programs (35, 81). Research on
risk factors may lead more naturally to intervention opportunities if studied from the
perspective of population level factors, particularly as they occur within specific
environments or socially patterned risk clusters and vulnerable sub-populations (82-85).
Health inequalities of interest from a policy perspective are those differences in health that
are judged unnecessary, preventable, and unjust (33, 35). Yet the obvious consequence of
such a definition is that these classifications cannot be based on scientific evidence alone.
Ideology, values, and political perspectives are all necessarily part of the process of
determining these classifications. It is therefore naive to imagine that epidemiologists can
avoid subjectivity in the conduct and interpretation of their work, even while as scientists
they strive to provide the best evidence-based knowledge for effective policy development.
Epidemiologists bring a set of methodological and analytic skills to the last three cycles in
policy development: policy choices, policy implementation and policy evaluation (81).
Assessing potential interventions often requires synthesizing and evaluating evidence across
diverse applications and study designs. Though epidemiologists are often trained in
conducting systematic reviews, they are sometimes less prepared for the type of evaluation
necessary to identify cost effective and efficacious policy interventions. They must embrace
evaluation and dissemination at the beginning of the planning process, and seek funding to
support these tasks. Funders also should consider the need to support all phases of health
disparities research.
Acknowledgments
We gratefully acknowledge comments from participants of the April 2011 American College of Epidemiology
policy committee meeting in St. Louis, Missouri, as well as suggestions of topics for potential cases from health
disparities researchers in response to our queries. We also acknowledge funding support from the American College
of Epidemiology and Washington University in St. Louis (Division of Public Health Sciences) for the April 2011
meeting, and from NIH DA 20826 (Mays) and CDC cooperative agreement 1 U48 DP001929 (Carter-Pokras) for
participation in preparation of this manuscript. The findings and conclusions in this article are those of the authors
and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the
Department of Health and Human Services.
Page 11
List of Abbreviations and Acronyms

AIDS
Acquired Immune Deficiency Syndrome
CARDIA
Coronary Artery Risk Development in Young Adults Study
CBOs
Community Based Organizations
CDC
Centers for Disease Control and Prevention
DALYs
Disability Adjusted Life-Years
EBT
Electronic Benefit Transfer
HIV
Human Immunodeficiency Virus
HHS
United States Department of Health and Human Services
LA
Los Angeles
ng/mL
Nanograms per milliter
RBC
Red Blood Cells
REACH
Racial and Ethnic Approaches to Community Health program
QALYs
Quality Adjusted Life-Years
SES
Socioeconomic status
SNAP
Supplemental Nutrition Assistance Program
US
United States
WIC
Women, Infants and Children
References
1. Brownson RC, Hartge P, Samet JM, Ness RB. From epidemiology to policy: toward more effective
practice. Ann Epidemiol. 2010 Jun; 20(6):409411. [PubMed: 20470966]
2. United States Census Bureau Population Division. Population Projections. U.S. Interim Projections
by Age, Sex, Race, and Hispanic Origin:2000-2050.
3. Ruffin J. The science of eliminating health disparities: Embracing a new paradigm. Am J Public
Health. 2010 Apr 1; 100(1):S89. [PubMed: 20147659]
4. Malone, TE.; Task Force Members. [Accessed on April 5, 2012] Report of the Secretary's Task
Force on Black & Minority Health. 1985. Available at http://minorityhealth.hhs.gov/assets/pdf/
checked/1/ANDERSON.pdf
5. Centers for Disease Control and Prevention. [Accessed on April 5, 2012] Publications and
Information Products Health, United States, annual report on trends in health statistics. Available at
http://www.cdc.gov/nchs/hus.htm
6. U.S. Department of Health & Human Services. [Accessed on April 5, 2012] Agency for Healthcare
Research and Quality 2010 National Healthcare Quality & Disparities Reports. Available at http://
www.ahrq.gov/qual/qrdr10.htm
7. U.S. Department of Health & Human Services. [Accessed on April 5, 2012] The Office of Minority
Health. Available at http://minorityhealth.hhs.gov/
8. Clinton, B. [Accessed on April 5, 2012] One America in the 21st Century: The President's Initiative
on Race. Mar. 1998 Available at https://www.ncjrs.gov/pdffiles/173431.pdf
9. U.S. Department of Health & Human Services. [Accessed on April 5, 2012] Healthy People 2020.
Available at http://healthypeople.gov/2020/default.aspx
10. U.S. Department of Health & Human Services. [Accessed on April 5, 2012] National Partnership
for Action to End Health Disparities. HHS Action Plan to Reduce Racial and Ethnic Health
Page 12

Disparities. Available at http://www.minorityhealth.hhs.gov/npa/files/Plans/HHS/

HHS_Plan_complete.pdf
11. Office of Management and Budget. Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity. 1997; 62:5878158790. Federal Register.
12. Weed DL. Science, ethics guidelines, and advocacy in epidemiology. Ann Epidemiol. 1994 Mar;
4(2):16671. [PubMed: 8205285]
13. Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation of disparities
research to achieve health equity. Annu Rev Public Health. 2011 Apr 21.32:399416. [PubMed:
21219164]
14. Airhihenbuwa CO, Laveist TA. Racial and ethnic approaches to community health (REACH)
2010. Health Promot Pract. 2006; 7(3 Suppl):174S5S. [PubMed: 16940031]
15. Matyas, ML.; Haley-Oliphant, AE., editors. Women Life Scientists: Past, Present, and FutureConnecting Role Models to the Classroom Curriculum. The American Physiological Society;
1997.
16. Bollet A. Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century.
Yale J Biol Med. 1992; 65(3):21121. [PubMed: 1285449]
17. Cohen DA, Scribner RA, Farley TA. A structural model of health behavior: a pragmatic approach
to explain and influence health behaviors at the population level. Prev Med. 2000 Feb; 30(2):146
54. [PubMed: 10656842]
18. Slater SJ, Nicholson L, Chriqui J, Turner L, Chaloupka F. The Impact of State Laws and District
Policies on Physical Education and Recess Practices in a Nationally Representative Sample of US
Public Elementary Schools. Archives of Pediatrics & Adolescent Medicine. 201110.1001/
archpediatrics.2011.1133
19. Story M, Nanney MS, Schwartz MB. Schools and obesity prevention: creating school
environments and policies to promote healthy eating and physical activity. Milbank Q. 2009 Mar;
87(1):71100. [PubMed: 19298416]
20. Joffe M, Mindell J. Complex Causal Process Diagrams for Analyzing the Health Impacts of Policy
Interventions. Am J Public Health. 2006; 96(3):4739. [PubMed: 16449586]
21. Task Force on Community Preventive Services. Recommendations from the Task Force on
Community Preventive Services to decrease asthma morbidity through home-based, multi-trigger,
multicomponent interventions. Am J Prev Med. 2011; 41(2S1):S14. [PubMed: 21767733]
22. Jacobs DE, Brown MJ, Baeder A, Sucosky MS, Margolis S, Hershovitz J, Kolb L, Morley RL. A
Systematic Review of Housing Interventions and Health: Introduction, Methods, and Summary
Findings. J Public Health Management Practice. 2010; 16 E-Supp(5):S5S10.
23. Oakes, JM.; Kaufman, JS. Methods in Social Epidemiology. San Francisco, CA: Jossey-Bass;
2006.
24. Greenland S, Pearl J, Robins JM. Causal diagrams for epidemiologic research. Epidemiology. 1999
Jan; 10(1):3748. [PubMed: 9888278]
25. Glymour, MM.; Greenland, S. Causal diagrams. In: Rothman, KJ.; Greenland, S.; Lash, TL.,
editors. Modern Epidemiology. 3rd. Philadelphia PA: Lippincott Williams & Wilkins; p. 2008p.
183-209.
26. Tzivian L. Outdoor air pollution and asthma in children. J Asthma. 2011 Jun; 48(5):47081.
[PubMed: 21486196]
27. Johnston SL, Pattemore PK, Sanderson G, Smith S, Lampe F, Josephs L, et al. Community study
of role of viral infections in exacerbations of asthma in 911 year old children. BMJ. 1995;
310(6989):12259. [PubMed: 7767192]
28. Krieger J, Jacobs DE, Ashley PJ, Baeder A, Chew GL, Dearborn D, Hynes HP, et al. Housing
interventions and control of asthma-related indoor biologic agents: a review of the evidence. J
Public Health Manag Pract. 2010 Sep-Oct;16(5 Suppl):S1120. [PubMed: 20689369]
29. Reisman RE, Mauriello PM, Davis GB, Georgitis JW, Demasi JM. A double-blind-study of the
effectiveness of a highefficiency particulate air (HEPA) filter in the treatment of patients with
perennial allergic rhinitis and asthma. J Allergy Clin Immunol. 1990; 85(6):10501057. [PubMed:
2191991]
Page 13

30. Greenland, S. Ch. 22: Overthrowing the Tyranny of Null Hypotheses Hidden in Causal Diagrams.
In: Dechter, R.; Geffner, H.; Halpern, JY., editors. Heuristics, Probabilities, and Causality: A
Tribute to Judea Pearl. College Publications; p. 2010p. 365-382.
31. Meyer BD. Natural and Quasi-Experiments in Economics. Journal of Business & Economic
Statistics. 1995; 13(2):151161.
32. Prieto L, Sacristn JA. Problems and solutions in calculating quality-adjusted life years (QALYs).
Health Qual Life Outcomes. 2003 Dec 19.1(80) Available from: http://www.hqlo.com/content/pdf/
1477-7525-1-80.pdf.
33. Carter-Pokras O, Baquet C. What is a health disparity? Public Health Reports. 2002; 117:426432.
[PubMed: 12500958]
34. Keppel K, Pamuk E, Lynch J, Carter-Pokras O, Kim I, Mays V, Pearcy J, Schoenbach V,
Weissman JS. Methodological Issues in Measuring Health Disparities. National Center for Health
Statistics. Vital Health Stat. 2005; 2(141)
35. Braveman P. Health disparities and health equity: Concepts and measurement. Annu Rev Public
Health. 2006; 27:16794. [PubMed: 16533114]
36. Harper S, King NB, Meersman SC, Reichman ME, Breen N, Lynch J. Implicit value judgments in
the measurement of health inequalities. Milbank Q. 2010; 88(1):429. [PubMed: 20377756]
37. James SA. Epidemiologic research on health disparities: Some thoughts on history and current
developments. Epidemiol Rev. 2009; 31(1):16. [PubMed: 19822533]
38. Harper S, Lynch J, Meersman SC, Breen N, Davis WW, Reichman ME. An overview of methods
for monitoring social disparities in cancer with an example using trends in lung cancer incidence
by area-socioeconomic position and race-ethnicity, 1992-2004. Am J Epidemiol. 2008; 167(8):
88999. [PubMed: 18344513]
39. Messer LC. Measuring social disparities in health--what was the question again? Am J Epidemiol.
2008; 167(8):9004. [PubMed: 18344512]
40. Scanlan JP. Can we actually measure health disparities? Chance. 2006; 19(2):4751.
41. Krieger N, Williams DR. Changing to the 2000 standard million: are declining racial/ethnic and
socioeconomic inequalities in health real progress or statistical illusion? Am J Public Health. 2001
Aug; 91(8):120913. [PubMed: 11499105]
42. Sebelius, K. Washington DC: Department of Health and Human Services; 2011 Sept.. Report to
Congress. Approaches for Identifying, Collecting, and Evaluating Data on Health Care Disparities
in Medicaid and CHIP. Available from: http://www.healthcare.gov/law/resources/reports/
index.html [Accessed on April 5, 2012]
43. HHS Office of Minority Health; US Department of Health and Human Services. [Accessed on
April 5, 2012] Final Data Collection Standards for Race, Ethnicity, Primary Language, Sex, and
Disability Status Required by Section 4302 of the Affordable Care Act. 2011. Available: http://
minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=208
44. HHS Office of Minority Health; US Department of Health and Human Services. [Accessed on
April 5, 2012] Plan for Health Data Collection on Lesbian, Gay, Bisexual and Transgender
(LGBT) Populations. 2011. Available: http://minorityhealth.hhs.gov/templates/browse.aspx?
lvl=2&lvlid=208
45. Committee on Leading Health Indicators For Healthy People 2020. Leading Health Indicators For
Healthy People 2020: Letter Report. National Academics Press: Washington, DC; 2010.
46. Salsbury, B.; O'Keefe, E.; Kertanis, J. Chapter 23. Measuring Social Determinants of Health
Inequities: The CADH Health Equity Index. In: Hofrichter, R.; Bhatia, R., editors. Tackling Health
Inequities through Public Health Practice: Theory to Action. New York, NY: Oxford University
Press; 2010.
47. Whakapuakanga: Ministry of Social Development. Ministry of Social Development; New Zealand:
2010. 2010 The Social ReportTe Purongo Oranga Tangata. Available at: http://
www.communityresearch.org.nz/wp-content/uploads/tdomf/4097/the-social-report-2010.pdf
[Accessed on April 5, 2012]
48. Bloom B, Cohen RA, Freeman G. Summary health statistics for U.S. children: National Health
Interview Survey, 2009. Vital Health Stat. 2010 Dec; 10(247):182.
Page 14

49. Digenis-Bury EC, Brooks DR, Chen L, Ostrem M, Horsburgh CR. Use of a population-based
survey to describe the health of Boston public housing residents. Am J Public Health. 2008 Jan;
98(1):8591. [PubMed: 18048798]
50. Northridge J, Ramirez OF, Stingone JA, Claudio L. The role of housing type and housing quality
in urban children with asthma. J Urban Health. 2010 Mar; 87(2):21124. [PubMed: 20063071]
51. Krieger, JW.; Takaro, TK.; Rabkin, JC. Chapter 19. Breathing easier in Seattle: addressing asthma
disparities through healthier housing. In: Williams, RA., editor. Healthcare Disparities at the
Crossroads with Healthcare Reform. Springer: 2011. p. 359-385.
52. Guide to Community Preventive Services. Asthma control: home-based multi-trigger,
multicomponent interventions. www.thecommunityguide.org/asthma/multicomponent.htmlLast
updated: 11/17/2011
53. Krieger JW, Song L, Takaro TK, Stout J. Asthma and the home environment of low-income urban
children: preliminary findings from the Seattle-King County healthy homes project. Urban Health.
2000 Mar; 77(1):5067.
54. Krieger JW, Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes Project: a
randomized, controlled trial of a community health worker intervention to decrease exposure to
indoor asthma triggers. Am J Public Health. 2005 Apr; 95(4):6529. [PubMed: 15798126]
55. Krieger, JW.; Takaro, TK.; Rabkin, JC. Chapter 15. Breathe easy in Seattle: addressing asthma
disparities through healthier housing. In: Williams, RA., editor. Eliminating healthcare disparities
in America. Totowa, NJ: Humana Press; 2007. p. 313-339.
56. Margellos-Anast, H.; Gutierrez, MA. Chapter 11. Pediatric asthma in black and Latino Chicago
communities: local level data drives response. In: Whitman, S.; Shah, AM.; Benjamins, MR.,
editors. Urban Health: combating disparities with local data. New York, NY: Oxford University
Press; 2011.
57. Parker EA, Israel BA, Robins TG, Mentz G, Lin X, Brakefield-Caldwell W, et al. Evaluation of
community action against asthma: a community health worker intervention to improve children's
asthma-related health by reducing household environmental triggers of asthma. Health Education
and Behavior. 2008; 35(3):376395. [PubMed: 17761540]
58. Spielman SE, Golembeski CA, Northridge ME, Vaughan RD, Swaner R, Jean-Louis B, et al.
Interdisciplinary planning for healthier communities: findings from the Harlen Children's Zone
Asthma Initiative. Journal of the American Planning Association. 2006; 73:100108.
59. Whitman, S.; Shah, AM.; Benjamins, MR. Chapter 1. Introducing the Sinai model for reducing
health disparities and improving health. In: Whitman, S.; Shah, AM.; Benjamins, MR., editors.
Urban Health: combating disparities with local data. New York, NY: Oxford University Press;
2011.
60. Saegert SC, Klitzman S, Freudenberg N, Cooperman-Mroczek J, Nassar S. Healthy Housing: A
Structured Review of Published Evaluations of US Interventions to Improve Health by Modifying
Housing in the United States, 19902001. Am J Public Health. 2003; 93(9):14711477. [PubMed:
12948965]
61. National Center for Healthy Housing. Housing Interventions and Health: A Review of the
Evidence. 2009
62. Krieger JK, Takaro TK, Allen C, Song L, Weaver M, Chai S, Dickey P. The Seattle-King County
healthy homes project: implementation of a comprehensive approach to improving indoor
environmental quality for low-income children with asthma. Environ Health Perspect. 2001 Apr;
110(2):31122. [PubMed: 11929743]
63. Gtzsche PC, Johansen HK. House dust mite control measures for asthma. Cochrane Database Syst
Rev. 2008; (2) Art. No.: cd001187. 10.1002/14651858.cd001187.pub3
64. Sauni R, Uitti J, Jauhiainen M, Kreiss K, Sigsgaard T, Verbeek JH. Remediating buildings
damaged by dampness and mould for preventing or reducing respiratory tract symptoms,
infections and asthma. Cochrane Database Syst Rev. 2011 Sep 7.9:CD007897. [PubMed:
21901714]
65. Jacobs DE, Brown MJ, Baeder A, et al. A systematic review of housing interventions and health:
introduction, methods, and summary findings. J Public Health Management Practice. 2010; 16 ESupp(5):S5, S10.
Page 15

66. Krieger J, Jacobs DE, Ashley P, Peter J, et al. Housing Interventions and Control of AsthmaRelated Indoor Biologic Agents: A Review of the Evidence. Journal of Public Health Management
& Practice. 2010; 16(5):S11S20. [PubMed: 20689369]
67. Takaro TK, Krieger J, Song L, Sharify D, Beaudet N. The Breathe-Easy Home: the impact of
asthma-friendly home construction on clinical outcomes and trigger exposure. Am J Public Health.
2011 Jan; 101(1):5562. [PubMed: 21148715]
68. Carter-Pokras OD, Spirtas R, Bethune L, Mays V, Freeman VL, Cozier YC. The training of
epidemiologists and diversity in epidemiology: findings from the 2006 Congress of Epidemiology
survey. Annals of epidemiology. 2009; 19(4):26875. [PubMed: 19344867]
69. Giang T, Karpyn A, Laurison HB, Hillier A, Perry RD. Closing the grocery gap in underserved
communities: the creation of the Pennsylvania Fresh Food Financing Initiative. J Public Health
Manag Pract. 2008 May-Jun;14(3):2729. [PubMed: 18408552]
70. Bassford, N.; Galloway-Gilliam, L.; Flynn, G. CHC Food Resource Development Workgroup.
Food Desert to Food Oasis: Promoting Grocery Store Development in South Los Angeles.
Community Health Councils, Inc.; Los Angeles, CA: 2010. Available at: http://www.chc-inc.org/
downloads/Food%20Desert%20to%20Food%20Oasis%20July%202010.pdf [Accessed on April
16, 2012]
71. Plescia M, Herrick H, Chavis L. Improving health behaviors in an African American Community:
The Charlotte Racial and Ethnic Approaches to Community Health Project. Am J Public Health.
2008; 98(9):16781684. [PubMed: 18633087]
72. Community Health Councils. Los Angeles, CA: Community Health Councils; 2008 Apr 8. Does
race define what's in the shopping cart. Available from: http://www.chc-inc.org/section.php?id=22
[Accessed on April 5, 2012]
73. Helmer, J. [Accessed on April 5, 2012] South L.A. Fights Food Deserts: South Los Angeles has
begun to say bye-bye to burgers and fries through its ordinance to limit fast-food restaurants.
Urban Farm Online.Com. 2011 Mar 1. Available: http://www.urbanfarmonline.com/urban-farmnews/2011/03/01/south-la-fights-food-deserts.aspx
74. MacVean, M.; South, LA. [Accessed on April 5, 2012] South L.A. gets a new supermarket. Los
Angeles Times. 2010 Feb 24. Available: http://latimesblogs.latimes.com/dailydish/2010/02/southla-gets-a-new-supermarket.html
75. Strum R, Cohen D. Zoning for Health? The Year-Old Ban on New Fast-Food Restaurants in South
LA: The Ordinance Isn't a Promising Approach to Attacking Obesity. Health Affairs. 2009; 28(6):
10881097.
76. Boone-Heinonen J, Gordon-Larsen P, Kiefe CI, Shikany JM, Lewis CE, Popkin BM. Fast food
restaurants and food stores: longitudinal associations with diet in young to middle-aged adults: the
CARDIA study. Arch Intern Med. 2011 Jul 11; 171(13):116270. [PubMed: 21747011]
77. Briggs S, Fisher A, Lott M, Miller S, Tessman N. Real Food, Real Choice: Connecting Snap
Recipients with Farmers Markets. Community Food Security Coalition | Farmers Market
Coalition. Jun.2010
78. Erickson JD, Mulinare J, Yang Q, et al. Folate status in women of childbearing age, by race/
ethnicityUnited States, 1999-2000. MMWR. 2002; 51(36):808810. [PubMed: 12269469]
79. Cordero A, Mulinare J, Boyle C, Dietz W, Johnston R Jr, Leighton J, Popovic T. CDC Grand
Rounds: Additional Opportunities to Prevent Neural Tube Defects with Folic Acid Fortification.
MMWR. 2010 Aug 13;59(31):980984. [PubMed: 20703205]
80. Mays, VM.; Maas, R.; Ricks, J.; Cochran, SD. HIV and African American Women in the South:
Employing A Population-Level HIV Prevention and Intervention Efforts. In: Baum, A.; Revenson,
R.; Singer, J., editors. Handbook of Health Psychology. New York: Oxford Press; 2011. p.
771-801.
81. Spasoff, RA. Epidemiologic Methods for Health Policy. New York, NY: Oxford University Press;
1999.
82. Farley TA. Sexually transmitted diseases in the Southeastern United States: location, race, and
social context. Sex Transm Dis. 2006 Jul; 33(7 Suppl):S5864. [PubMed: 16432486]
83. Mays, V.; Maas, R.; Ricks, J.; Cochran, SD. HIV in African American Women: A Social
Determinants Approach in Population-Level HIV Prevention Intervention. In: Baum, A.;
Page 16
Revenson, TA.; Singer, J., editors. A Handbook of Health Psychology. 2nd. Florence, KY:
Psychology Press; 2011.
84. Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. Int J
Drug Policy. 2009 May; 20(3):193201. Epub 2009 Jan 14. [PubMed: 19147339]
85. Rhodes T, Stimson GV, Crofts N, Ball A, Dehne K, Khodakevich L. Drug injecting, rapid HIV
spread, and the risk environment: implications for assessment and response. AIDS. 1999;
13(A):S25969. [PubMed: 10885783]

Page 17
Box 1
Five key steps of the policy cycle

1.
Assessment of population health
2.
Assessment of potential interventions
3.
Policy choices
4.
Policy implementation
5.
Policy evaluation

Page 18

Figure 1.
Proposed graphical representation illustrating the dependency assumptions for the influence
of policy and caregiver decision-making to improve poor living conditions (i.e., reduce
indoor allergens) on the occurrence of childhood asthma exacerbations


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Epidemiology, Policy, and Racial/Ethnic Minority Health

of Epidemiology, School of Public Health, University of North Texas Health Science

of Epidemiology, Biostatistics, and Occupational Health, McGill University

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of Health Services, School of Public Health, and Department of Psychology

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2012 Elsevier Inc. All rights reserved.

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Health Status Disparities; Healthcare Disparities; Minority Health; Epidemiology; Policy;

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Ann Epidemiol. Author manuscript; available in PMC 2013 July 26.

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Theoretical Framework for Causal Effects of Policies

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To estimate the causal effect on childhood asthma exacerbations of a potential policy of

Ann Epidemiol. Author manuscript; available in PMC 2013 July 26.

The Role of Epidemiology in Definition and Measurement

A primary goal of epidemiologic research is to provide an evidentiary basis for informed

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Epidemiologic study of social determinants in relation to health disparities entails many

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Ann Epidemiol. Author manuscript; available in PMC 2013 July 26.

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The Example of Housing and Asthma

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location/development of potentially effective interventions, work with community based

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Evidence is lacking or mixed for key components of multilevel housing interventions in

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For epidemiologists to more fully contribute to development and evaluation of interventions

Food Policy Strategies to Reduce Health Disparities

Ann Epidemiol. Author manuscript; available in PMC 2013 July 26.

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In addition to increasing access to healthy foods, another important strategy is decreasing

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Ann Epidemiol. Author manuscript; available in PMC 2013 July 26.

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Ann Epidemiol. Author manuscript; available in PMC 2013 July 26.

List of Abbreviations and Acronyms

Acquired Immune Deficiency Syndrome

Coronary Artery Risk Development in Young Adults Study

Community Based Organizations

Centers for Disease Control and Prevention

Disability Adjusted Life-Years

Electronic Benefit Transfer

Human Immunodeficiency Virus

United States Department of Health and Human Services

Nanograms per milliter